Josef I. Ruzek, Ph.D., Erika Curran, M.S.W.,
Matthew J. Friedman, M.D., Ph.D., Fred D. Gusman, M.S.W., Steven
M. Southwick, M.D., Pamela Swales, Ph.D., Robyn D. Walser, Ph.D.,
Patricia J. Watson, Ph.D., and Julia Whealin, Ph.D.
In this section from the Iraq War Clinician Guide, we discuss treatment of veterans recently evacuated due to combat or war stress who are brought to
the VA for mental health care, and Iraq War veterans seeking mental
health care at VA medical centers and Vet Centers.
This section complements discussion of special topics (e.g.,
treatment of medical casualties, identification and management of
PTSD in the primary care setting, issues in caring for veterans who
have been sexually assaulted, traumatic bereavement) that are
addressed in other sections of this Guide.
It is important that VA and Vet Center clinicians recognize that
the skills and experience that they have developed in working with
veterans with chronic PTSD will serve them well with those
returning from the Iraq War. Their experience in talking about
trauma, educating patients and families about traumatic stress
reactions, teaching skills of anxiety and anger management,
facilitating mutual support among groups of veterans, and working
with trauma-related guilt, will all be useful and applicable. Here,
we highlight some challenges for clinicians, discuss ways in which
care of these veterans may differ from our usual contexts of care,
and direct attention to particular methods and materials that may
be relevant to the care of the veteran recently traumatized in
war.
The Helping Context: Active Duty vs. Veterans Seeking Health Care
There are a variety of differences between the contexts of care
for active duty military personnel and veterans normally being
served in VA that may affect the way practitioners go about their
business. First, many Iraq War patients will not be seeking mental
health treatment. Some will have been evacuated for mental health
or medical reasons and brought to VA, perhaps reluctant to
acknowledge their emotional distress and almost certainly reluctant
to consider themselves as having a mental health disorder (e.g.,
post-traumatic stress disorder). Second, emphasis on diagnosis as
an organizing principle of mental health care is common in VA.
Patients are given DSM-IV diagnoses, and diagnoses drive treatment.
This approach may be contrasted with that of frontline psychiatry,
in which pathologization of combat stress reactions is strenuously
avoided. The strong assumption is that most soldiers will recover,
and that their responses represent a severe reaction to the
traumatic stress of war rather than a mental illness or disorder.
According to this thinking, the “labeling” process may
be counterproductive in the context of early care for Iraq War
veterans. As Koshes
1 noted, “labeling a person with an illness can
reinforce the “sick” role and delay or prevent the
soldier’s return to the unit or to a useful role in military
or civilian life” (p. 401).
Patients themselves may have a number of incentives to minimize
their distress: to hasten discharge, to accelerate a return to the
family, to avoid compromising their military career or retirement.
Fears about possible impact on career prospects are based in
reality; indeed, some will be judged medically unfit to return to
duty. Veterans may be concerned that a diagnosis of PTSD, or even
Acute Stress Disorder, in their medical record may harm their
chances of future promotion, lead to a decision to not be retained,
or affect type of discharge received. Some may think that the
information obtained if they receive mental health treatment will
be shared with their unit commanders, as is sometimes the case in
the military.
To avoid legitimate concerns about possible pathologization of
common traumatic stress reactions, clinicians may wish to consider
avoiding, where possible, the assignment of diagnostic labels such
as ASD or PTSD, and instead focus on assessing and documenting
symptoms and behaviors. Diagnoses of acute or adjustment disorders
may apply if symptoms warrant labeling. Concerns about
confidentiality must be acknowledged and steps taken to create the
conditions in which patients will feel able to talk openly about
their experiences, which may include difficulties with commanders,
misgivings about military operations or policies, or possible moral
concerns about having participated in the war. It will be helpful
for clinicians to know who will be privy to information obtained in
an assessment. The role of the assessment and who will have access
to what information should be discussed with concerned
patients.
Active duty service members may have the option to remain on
active duty or to return to the war zone. Some evidence suggests
that returning to work with one’s cohort group during wartime
can facilitate improvement of symptoms. Although their wishes may
or may not be granted, service members often have strong feelings
about wanting or not wanting to return to war. For recently
activated National Guard and Reservists, issues may be somewhat
different.
2 Many in this population never planned to go to war and so
may be faced with obstacles to picking up the life they
“left.” Whether active duty, National Guard, or
Reservist, listening to and acknowledging their concerns will help
empower them and inform treatment planning.
Iraq War patients entering residential mental health care will
have come to the VA through a process different from that
experienced by “traditional” patients. If they have
been evacuated from the war zone, they will have been rapidly moved
through several levels of medical triage and treatment, and treated
by a variety of health care providers.
3 Many will have received some mental health care in the war
zone (e.g., stress debriefing) that will have been judged
unsuccessful. Some veterans will perceive their need for continuing
care as a sign of personal failure.Understanding their path to the
VA will help the building of a relationship and the design of
care.
More generally, the returning soldier is in a state of
transition from war zone to home, and clinicians must seek to
understand the expectations and consequences of returning home for
the veteran. Is the veteran returning to an established place in
society, to an economically deprived community, to a supportive
spouse or cohesive military unit, to a large impersonal city, to
unemployment, to financial stress, to an American public thankful
for his or her sacrifice? Whatever the circumstances, things
are unlikely to be as they were:
“The deployment of the family member creates a
painful void within the family system that is eventually filled (or
denied) so that life can go on…The family assumes that their
experiences at home and the soldier’s activities on the
battlefield will be easily assimilated by each other at the time of
reunion and that the pre-war roles will be resumed. The fact
that new roles and responsibilities may not be given up quickly
upon homecoming is not anticipated.”(p.31).
4
Learning from Vietnam Veterans with Chronic PTSD
From the perspective of work with Vietnam veterans whose lives
have been greatly disrupted by their disorder, the chance to work
with combat veterans soon after their war experiences represents a
real opportunity to prevent the development of a disastrous life
course. We have the opportunity to directly focus on traumatic
stress reactions and PTSD symptom reduction (e.g., by helping
veterans process their traumatic experiences, by prescribing
medications) and thereby reduce the degree to which PTSD,
depression, alcohol/substance misuse, or other psychological
problems interfere with quality of life. We also have the
opportunity to intervene directly in key areas of life functioning,
to reduce the harm associated with continuing post-traumatic stress
symptoms and depression if those prove resistant to treatment. The
latter may possibly be accomplished via interventions focused on
actively supporting family functioning in order to minimize family
problems, reducing social alienation and isolation, supporting
workplace functioning, and preventing use of alcohol and drugs as
self-medication (a different focus than addressing chronic alcohol
or drug problems).
Prevent family breakdown
At time of return to civilian life, soldiers can face a variety of
challenges in re-entering their families, and the contrast
between the fantasies and realities of homecoming
4 can be distressing. Families themselves have been stressed
and experienced problems as a result of the deployment.
5,
6 Partners have made
role adjustments while the soldier was away, and these need to be
renegotiated, especially given the possible irritability and
tension of the veteran.
7 The possibility exists that mental health providers can
reduce long term family problems by helping veterans and their
families anticipate and prepare for family challenges, involving
families in treatment, providing skills training for patients
(and where possible, their families) in family-relevant skills
(e.g., communication, anger management, conflict resolution,
parenting), providing short-term support for family members, and
linking families together for mutual support.
Prevent social withdrawal and isolation
PTSD also interferes with social functioning. Here the challenge is
to help the veteran avoid withdrawal from others by supporting
re-entry into existing relationships with friends, work
colleagues, and relatives, or where appropriate, assisting in
development of new social relationships. The latter may be
especially relevant with individuals who leave military service
and transition back into civilian life. Social functioning should
be routinely discussed with patients and made a target for
intervention. Skills training focusing on the concrete management
of specific difficult social situations may be very helpful.
Also, as indicated below, clinicians should try to connect
veterans with other veterans in order to facilitate the
development of social networks.
Prevent problems with employment
Associated with chronic combat-related PTSD have been high rates of job
turnover and general difficulty in maintaining employment, often
attributed by veterans themselves to anger and irritability,
difficulties with authority, PTSD symptoms, and substance abuse.
Steady employment, however, is likely to be one predictor of
better long term functioning, as it can reduce financial
stresses, provide a source of meaningful activity and
self-esteem, and give opportunities for companionship and
friendship. In some cases, clinicians can provide valuable help
by supporting the military or civilian work functioning of
veterans, by teaching skills of maintaining or, in the case of
those leaving the military, finding of employment, or
facilitating job-related support groups.
Prevent alcohol and drug abuse
The co-morbidity of PTSD with alcohol and drug problems in veterans is well
established.
8 Substance abuse adds to the problems caused by PTSD and
interferes with key roles and relationships, impairs coping, and
impairs entry into and ongoing participation in treatment. PTSD
providers are aware of the need to routinely screen and assess for
alcohol and drug use, and are knowledgeable about alcohol and drug
(especially 12-Step) treatment. Many are learning, as well, about
the potential usefulness of integrated PTSD-substance abuse
treatment, and the availability of manualized treatments for this
dual disorder. “Seeking Safety,” a structured group
protocol for trauma-relevant coping skills training,
9 is seeing increased use in VA and should be considered as a
treatment option for Iraq War veterans who have substance use
disorders along with problematic traumatic stress responses. In
addition, for many newly returning Iraq War veterans, it will be
important to supplement traditional abstinence-oriented treatments
with attention to milder alcohol problems, and in particular to
initiate preventive interventions to reduce drinking or prevent
acceleration of alcohol consumption as a response to PTSD symptoms.
10 For
allreturning veterans, it will be
useful to provide education about safe drinking practices and the
relationship between traumatic stress reactions and substance
abuse.
General Considerations in Care
Connect with the returning veteran
As with all mental health counseling, the relationship between veteran and
helper will be the starting point for care. Forming a working
alliance with some returnees may be challenging, however, because
most newly-returned veterans may be, as Litz (this Guide) notes,
“defended, formal, respectful, laconic, and cautious”
and reluctant to work with the mental health professional.
Especially in the context of recent exposure to war, validation
7 of the veteran’s experiences and concerns will be
crucial. Discussion of “war zone”, not
“combat,” stress may be warranted because some
traumatic stressors (e.g., body handling, sexual assault) may not
involve war fighting as such. Thought needs to be given to making
the male-centric hospital system hospitable for women, especially
for women who have experienced sexual assault in the war zone
(see Special Topic VI, this Guide), for whom simply walking onto
the grounds of a VA hospital with the ubiquitous presence of men
may create feelings of vulnerability and anxiety.
Practitioners should work from a patient-centered perspective,
and take care to find out the current concerns of the patient
(e.g., fear of returning to the war zone, concerns about having
been evacuated and what this means, worries about reactions of
unit, fear of career ramifications, concern about reactions of
family, concerns about returning to active duty). One advantage of
such an orientation is that it will assist with the development of
a helping relationship.
Connect veterans with each other
In treatment of chronic PTSD, veterans often report that perhaps their most
valued experience was the opportunity to connect in friendship
and support with other vets. This is unlikely to be different for
returning Iraq War soldiers, who may benefit greatly from
connection both with each other and with veterans of other
conflicts. Fortunately, this is a real strength of VA and Vet
Center professionals, who routinely and skillfully bring veterans
together.
Offer practical help with specific problems
Returning veterans are likely to feel overwhelmed with problems, related to
workplace, family and friends, finances, physical health, and so
on. These problems will be drawing much of their attention away
from the tasks of therapy, and may create a climate of continuing
stress that interferes with resolution of symptoms. The presence
of continuing negative consequences of war deployment may help
maintain post-traumatic stress reactions. Rather than treating
these issues as distractions from the task at hand, clinicians
can provide a valuable service by helping veterans identify,
prioritize, and execute action steps to address their specific
problems.
Attend to broad needs of the person
Wolfe, Keane, and Young
11 put forward several suggestions for clinicians serving
Persian Gulf War veterans that are also important in the context
of the Iraq War. They recommended attention to the broad range of
traumatic experience (see Section I of this Guide). They
similarly recommended broad clinical attention to the impact of
both pre-military and post-military stressors on adjustment. For
example, history of trauma places those exposed to trauma in the
war zone at risk for development of PTSD, and in some cases war
experiences will activate emotions experienced during earlier
events. Finally, recognition and referral for assessment of the
broad range of physical health concerns and complaints that may
be reported by returning veterans is important. Mental health
providers must remember that increased health symptom reporting
is unlikely to be exclusively psychogenic in origin.
12
Methods of Care: Overview
Management of acute stress reactions and problems faced by
recently returned veterans are highlighted below. Methods of care
for the Iraq War veteran with PTSD will be similar to those
provided to veterans with chronic PTSD.
Education about post-traumatic stress reactions
Education is a key component of care for the veteran returning from war
experience and is intended to improve understanding and
recognition of symptoms, reduce fear and shame about symptoms,
and, generally, “normalize” his or her experience. It
should also provide the veteran with a clear understanding of how
recovery is thought to take place, what will happen in treatment,
and, as appropriate, the role of medication. With such
understanding, stress reactions may seem more predictable and
fears about long-term effects can be reduced. Education in the
context of relatively recent traumatization (weeks or months)
should include the conception that many symptoms are the result
of psychobiological reactions to extreme stress and that, with
time, these reactions, in most cases, will diminish. Reactions
should be interpreted as responses to overwhelming stress rather
than as personal weakness or inadequacy. In fact, some recent
research
13 suggests that survivors’ own responses to their
stress symptoms will in part determine the degree of distress
associated with those symptoms and whether they will remit.
Whether, for example, post-trauma intrusions cause distress may
depend in part on their meaning for the person (e.g.,
“I’m going crazy”).
Training in coping skills
Returning veterans experiencing recurrent intrusive thoughts and images,
anxiety and panic in response to trauma cues, and feelings of
guilt or intense anger are likely to feel relatively powerless to
control their emotions and thoughts. This helpless feeling is in
itself a trauma reminder. Because loss of control is so central
to trauma and its attendant emotions, interventions that restore
self-efficacy are especially useful.
Coping skills training is a core element in the repertoire of
many VA and Vet Center mental health providers. Some skills that
may be effective in treating Iraq War veterans include: anxiety
management (breathing retraining and relaxation), emotional
“grounding,” anger management, and communication.
However, the days, weeks, and months following return home may pose
specific situational challenges; therefore, a careful assessment of
the veteran’s current experience must guide selection of
skills. For example, training in communication skills might focus
on the problem experienced by a veteran in expressing positive
feelings towards a partner (often associated with emotional
numbing); anger management could help the veteran better respond to
others in the immediate environment who do not support the war.
Whereas education helps survivors understand their experience
and know what to do about it, coping skills training should focus
on helping them know how to do the things that will support
recovery. It relies on a cycle of instruction that includes
education, demonstration, rehearsal with feedback and coaching, and
repeated practice. It includes regular between-session task
assignments with diary self-monitoring and real-world practice of
skills. It is this repeated practice and real world experience that
begins to empower the veteran to better manage his or her
challenges (see Najavits
9 for a useful manual of trauma-related coping
skills).
Exposure therapy.
Exposure therapy is among the best-supported treatments for
PTSD.
14 It is designed to help veterans effectively confront their
trauma-related emotions and painful memories, and can be
distinguished from simple discussion of traumatic experience in
that it emphasizes repeated verbalization of traumatic memories
(see Foa & Rothbaum
15 for a detailed exposition of the treatment). Patients are
exposed to their own individualized fear stimuli repetitively,
until fear responses are consistently diminished. Often, in-session
exposure is supplemented by therapist-assigned and monitored
self-exposure to the memories or situations associated with
traumatization. In most treatment settings, exposure is delivered
as part of a more comprehensive “package” treatment; it
is usually combined with traumatic stress education, coping skills
training, and, especially, cognitive restructuring (see below).
Exposure therapy can help correct faulty perceptions of danger,
improve perceived self-control of memories and accompanying
negative emotions, and strengthen adaptive coping responses under
conditions of distress.
Cognitive restructuring
Cognitive therapy or restructuring, one of the best-validated PTSD
treatments,
14 is designed to help the patient review and challenge
distressing trauma-related beliefs. It focuses on educating
participants about the relationships between thoughts and
emotions, exploring common negative thoughts held by trauma
survivors, identifying personal negative beliefs, developing
alternative interpretations or judgments, and practicing new
thinking. This is a systematic approach that goes well beyond
simple discussion of beliefs to include individual assessment,
self-monitoring of thoughts, homework assignments, and real-world
practice. In particular, it may be a most helpful approach
to a range of emotions other than fear guilt, shame,
anger, depression that may trouble veterans. For example,
anger may be fueled by negative beliefs (e.g., about perceived
lack of preparation or training for war experiences, about harm
done to their civilian career, about perceived lack of support
from civilians). Cognitive therapy may also be helpful in helping
veterans cope with distressing changed perceptions of personal
identity that may be associated with participation in war or loss
of wartime identity upon return.
4
For those wishing to learn more about the approach, a useful
resource is the Cognitive Processing Therapy manual developed by
Resick and Schnicke,
16 which incorporates extensive cognitive restructuring and
limited exposure. Although designed for application to rape-related
PTSD, the methods can be easily adapted for use with veterans.
Kubany’s
17 work on trauma-related guilt may be helpful in addressing
veterans’ concerns about harming or causing death to
civilians.
Family counseling
Mental health professionals within VA and Vet Centers have a long tradition of
working with family members of veterans with PTSD. This same
work, including family education, weekend family workshops,
couples counseling, family therapy, parenting classes, or
training in conflict resolution, will be very important with Iraq
War veterans. Some issues in family work are discussed in more
detail below.
Early Interventions for ASD or PTSD
If Iraq War veterans arrive at VA medical centers very soon
(i.e., within several days or several weeks) following their trauma
exposure, the possibility for early intervention to prevent
development of PTSD will exist. Although cognitive-behavioral early
interventions have only been developed recently and have not yet
been tried with war-related acute stress disorder, they should be
considered as a treatment option for some returning veterans, given
their impact with other traumas and consistency with what is known
about treatment of more chronic PTSD. In civilian populations,
several randomized controlled trials have demonstrated that brief
(i.e., 4-5 session) individually-administered cognitive-behavioral
treatment, delivered around two weeks after a trauma, can prevent
PTSD in some survivors of motor vehicle accidents, industrial
accidents, and assault
18,
19 who meet criteria for
Acute Stress Disorder and are therefore at risk for development of
PTSD.
This treatment is comprised of education, breathing
training/relaxation, imaginal and
in vivo exposure, and cognitive restructuring. The exposure and cognitive restructuring elements of
the treatment are thought to be most helpful. A recent unpublished
trial conducted by the same team compared cognitive therapy and
exposure in early treatment of those with ASD, with results
indicating that both treatments were effective with fewer patients
dropping out of cognitive therapy. Bryant and Harvey
20 noted that prolonged exposure is not appropriate for
everyone (e.g., those experiencing acute bereavement, extreme
anxiety, severe depression, those experiencing marked ongoing
stressors or at-risk for suicide). Cognitive restructuring may have
wider applicability in that it may be expected to produce less
distress than exposure.
Toxic Exposure, Physical Health Concerns, and Mental
Health
War syndromes have involved fundamental, unanswered questions
about chronic somatic symptoms in armed conflicts since the U.S.
civil war.
21 In recent history, unexplained symptoms have been reported
by Dutch peacekeepers in Lebanon, Bosnia, and Cambodia, Russian
soldiers in Afghanistan and Chechnya, Canadian peacekeepers in
Croatia, soldiers in the Balkan war, individuals exposed to the El
Al airliner crash, individuals given the anthrax vaccine,
individuals exposed to the World Trade Center following 9/11, and
soldiers in the Gulf War. Seventeen percent of Gulf War
veterans believe they have “Gulf War Syndrome”.
22
Besides PTSD, modern veterans may experience a range of
“amorphous stress outcomes.”
23 Factors contributing to these more amorphous syndromes
include suspected toxic exposures, and ongoing chronic exhaustion
and uncertainty. Belief in exposure to toxic contaminants has a
strong effect on symptoms. Added to this, mistrust of military and
industry, intense and contradictory media focus, confusing
scientific debates, and stigma and medicalization can contribute to
increased anxiety and symptoms related to feared exposure to
contaminants.
When working with a recent veteran, the clinician needs to
address a full range of potentially disabling factors, to
include: harmful illness beliefs, weight and conditioning,
diagnostic labeling, misinformation, unnecessary testing,
over-medication, all or nothing rehabilitation approaches, medical
system rejection, social support, and workplace competition. The
provider needs to be familiar with side effects of suspected toxins
so that he or she can educate the veteran, as well as being
familiar with the potential somatic symptoms that are related to
prolonged exposure to combat stressors, and the side effects of
common medications. The provider should take a collaborative
approach with the patient, identifying the full range of
contributing problems, patient goals and motivation, social
support, and self-management strategies. A sustained follow-up is
recommended.
For those with inexplicable health problems, Fischoff and
Wessely
24 outlined some simple principles of patient management that
may be useful in the context of veteran care:
Focus communication around patients’ concerns
Organize information coherently
Give risks as numbers
Acknowledge scientific uncertainty
Use universally understood language
Focus on relieving symptoms
There is evidence that both cognitive-behavioral group therapy
(CBGT) and exercise are effective for treating Gulf War illness. In
a recent clinical trial, Donata et al.
25 reported that CBGT improved physical function whereas
exercise led to improvement in many of the symptoms of Gulf War
veterans’ illnesses. Both treatments improved cognitive
symptoms and mental health functioning, but neither improved pain.
In this study, CBGT was specifically targeted at physical
functioning, and included time-contingent activity pacing, pleasant
activity scheduling, sleep hygiene, assertiveness skills,
confrontation of negative thinking and affect, and structured
problem solving skills. The low-intensity aerobic exercise
intervention was designed to increase activity level by having
veterans exercise once per week for one hour in the presence of an
exercise therapist, and independently 2-3 times per week. These
findings are important because they demonstrate that such
treatments can be feasibly and successfully implemented in the VA
health care system, and thus should be considered for the treatment
of Iraq War veterans who present with unexplained physical
symptoms.
Family Involvement in Care
The primary source of support for the returning soldier is
likely to be his or her family. We know from veterans of the
Vietnam War that there can be a risk of disengagement from family
at the time of return from a war zone. We also know that emerging
problems with ASD and PTSD can wreak havoc with the competency and
comfort the returning soldier experiences as a partner and parent.
While the returning soldier clearly needs the clinician’s
attention and concern, that help can be extended to include his or
her family as well. Support for the veteran and family can increase
the potential for the veteran's smooth immediate or eventual
reintegration back into family life, and reduce the likelihood of
future more damaging problems.
Outpatient treatment
If the veteran is living at home, the clinician can meet with the family and
assess with them their strengths and challenges and identify any
potential risks. The "Transitioning Family Questionnaire"
(see Appendix A: Assessment Instrumentation) can be used to
assess to what extent the family is reorganizing to once again
fully include the family member who has been in the war zone.
Family and clinician can work together to identify goals and
develop a treatment plan to support the family's reorganization
and return to stability in coordination with the veteran's work
on his or her own personal treatment goals. The Transitioning
Family Questionnaire can be used again at a later date to assess
progress and/or need for continuing work.
If one or both partners are identifying high tension or levels
of disagreement, or the clinician is observing that their goals are
markedly incompatible, then issues related to safety need to be
assessed and plans might need to be made that support safety for
all family members. Couples who have experienced domestic violence
and/or infidelity are at particularly high risk and in need of more
immediate support. When couples can be offered a safe forum for
discussing, negotiating, and possibly resolving conflicts, that
kind of clinical support can potentially help to reduce the
intensity of the feelings that can become dangerous for a family.
Even support for issues to be addressed by separating couples can
be critically valuable, especially if children are involved and the
parents anticipate future co-parenting.
Residential rehabilitation treatment
Inpatient hospitalization could lengthen the time returning personnel are
away from their families, or it could be an additional absence
from the family for the veteran who has recently returned home.
It is important to the ongoing support of the reuniting family
that clinicians remain aware that their patient is a partner
and/or parent. Family therapy sessions, in person or by phone if
geographical distance is too great, can offer the family a forum
for working toward meeting their goals. The potential for the
involvement of the soldier’s family in treatment will
depend greatly on their geographic proximity to the treatment
facility. Distance can be a barrier, but the family can still be
engaged through conference phone calls, or visits as can be
arranged.
Pharmacotherapy
Pharmacologic treatment of acute stress reactions
Pharmacological treatment for acute stress reactions (within one month of the
trauma) is generally reserved for individuals who remain
symptomatic after having already received brief crisis-oriented
psychotherapy. This philosophy and approach is in line with the
deliberate attempt by military professionals to avoid
medicalizing stress-related symptoms and to adhere to a strategy
of immediacy, proximity, and positive
expectancy.
Prior to receiving medication for stress-related symptoms, the
war zone survivor should have a thorough psychiatric and medical
examination, with special emphasis on medical disorders that can
manifest with psychiatric symptoms (e.g., subdural hematoma,
hyperthyroidism), potential psychiatric disorders (e.g., acute
stress disorder, depression, psychotic disorders, panic disorder),
use of alcohol and substances of abuse, use of prescribed and
over-the-counter medication, and possible drug allergies. It is
important to assess the full range of potential psychiatric
disorders, and not just PTSD, since many symptomatic soldiers will
be at an age when first episodes of schizophrenia, mania,
depression, and panic disorder are often seen.
In some cases a clinician may need to prescribe psychotropic
medications even before he or she has completed the medical or
psychiatric examination. The acute use of medications may be
necessary when the survivor is dangerous, extremely agitated, or
psychotic. In such circumstances the individual should be taken to
an emergency room where short acting benzodiazepines (e.g.,
lorazepam) or high potency neuroleptics (e.g., haldol) with minimal
sedative, anticholinergic, and orthostatic side effects may prove
effective. Atypical neuroleptics (e.g., risperidone) may also be
useful for treating aggression.
When a decision has been made to use medication for acute stress
reactions, rational choices may include benzodiazepines,
antiadrenergics, or antidepressants. Shortly after traumatic
exposure, the brief prescription of benzodiazepines (4 days or
less)
has been shown to reduce extreme
arousal and anxiety and to improve sleep. However, early and
prolonged use of benzodiazepines is contraindicated, since
benzodiazepine use for two weeks or longer has actually has been
associated with a higher rate of subsequent PTSD.
Although antiadrenergic agents including clonidine, guanfacine,
prazosin, and propranolol have been recommended (primarily through
open non-placebo controlled treatment trials) for the treatment of
hyperarousal, irritable aggression, intrusive memories, nightmares,
and insomnia in survivors with chronic PTSD, there is only
suggestive preliminary evidence of their efficacy as an acute
treatment. Of importance, antiadrenergic agents should be
prescribed judiciously for trauma survivors with cardiovascular
disease due to potential hypotensive effects and these agents
should also be tapered, rather than discontinued abruptly, in order
to avoid rebound hypertension. Further, because
antiadrenergic agents might interfere with counterregulatory
hormone responses to hypoglycemia, they should not be prescribed to
survivors with diabetes.
Finally, the use of antidepressants may make sense within four
weeks of war, particularly when trauma-related depressive symptoms
are prominent and debilitating. To date, there has been one
published report on the use of antidepressants for the treatment of
Acute Stress Disorder. Recently-traumatized children meeting
criteria for Acute Stress Disorder, who were treated with
imipramine for two weeks, experienced significantly greater symptom
reduction than children who were prescribed chloral hydrate.
Pharmacologic treatment of post-traumatic stress disorder
Pharmacotherapy is rarely used as a stand-alone treatment for PTSD and is usually
combined with psychological treatment. The following text briefly
presents recommendations for the pharmaco-therapeutic treatment of
PTSD, and then the article by Friedman, Donnelly, and Mellman
26 in the Appendix provides more detailed information. Findings
from subsequent large-scale trials with paroxetine have
demonstrated that SSRI treatment is clearly effective both for men
in general and for combat veterans suffering
with PTSD.
We recommend SSRIs as first line medications for PTSD
pharmacotherapy in men and women with military-related PTSD. SSRIs
appear to be effective for all three PTSD symptom clusters in both
men and women who have experienced a variety of severe traumas and
they are also effective in treating a variety of co-morbid
psychiatric disorders, such as major depression and panic disorder,
which are commonly seen in individuals suffering with PTSD.
Additionally, the side effect profile with SSRIs is relatively
benign (compared to most psychotropic medications) although arousal
and insomnia may be experienced early on for some patients with
PTSD.
Second line medications include nefazadone, TCAs, and MAOIs.
Evidence favoring the use of these agents is not as compelling as
for SSRIs because many fewer subjects have been tested at this
point. The best evidence from open trials supports the use of
nefazadone, which like SSRIs promotes serotonergic actions and is
less likely than SSRIs to cause insomnia or sexual dysfunction.
Trazadone, which has limited efficacy as a stand-alone treatment,
has proven very useful as augmentation therapy with SSRIs; its
sedating properties make it a useful bedtime medication that can
antagonize SSRI-induced insomnia. Despite some favorable evidence
of the efficacy of MAOIs, these compounds have received little
experimental attention since 1990. Venlafaxine and buproprion
cannot be recommended because they have not been tested
systematically in clinical trials.
There is a strong rationale from laboratory research to consider
antiadrenergic agents and it is hoped that more extensive testing
will establish their usefulness for PTSD patients. The best
research on this class of agents has focused on prazosin, which has
produced marked reduction in traumatic nightmares, improved sleep,
and global improvement among veterans with PTSD. Hypotension and
sedation need to be monitored and patients should not be abruptly
discontinued from antiadrenergics.
Despite suggestive theoretical considerations and clinical
findings, there is only a small amount of evidence to support the
use of carbamazepine or valproate with PTSD patients.
Further, the complexities of clinical management with these
effective anticonvulsants have shifted current attention to newer
agents (e.g., gabapentin, lamotrigine, and topirimate), which have
yet to be tested systematically with PTSD patients.
Benzodiazepines cannot be recommended for patients with PTSD.
They do not appear to have efficacy against core PTSD patients. No
studies have demonstrated efficacy for PTSD-specific symptoms.
Conventional antipsychotics cannot be recommended for PTSD
patients. Preliminary results suggest, however, that atypical
antipsychotics may be useful, especially to augment treatment with
first or second line medications, especially for patients with
intense hypervigilance/paranoia, agitation, dissociation, or brief
psychotic reactions associated with their PTSD. As for side
effects, all atypicals may produce weight gain and olanzapine
treatment has been linked to the onset of Type II diabetes
mellitus.
General guidelines
Pharmacotherapy should be initiated with SSRI agents. Patients
who cannot tolerate SSRIs or who show no improvement might benefit
from nefazadone, MAOIs, or TCAs.
For patients who exhibit a partial response to SSRIs, one should
consider continuation or augmentation. A recent trial with
sertraline showed that approximately half of all patients who
failed to exhibit a successful clinical response after 12 weeks of
sertraline treatment, did respond when SSRI treatment was extended
for another 24 weeks. Practically speaking, clinicians and patients
usually will be reluctant to stick with an ineffective medication
for 36 weeks, as in this experiment. Therefore, augmentation
strategies seem to make sense. Here are a few suggestions based on
clinical experience and pharmacological “guesstimates,”
rather than on hard evidence:
Excessively aroused, hyperreactive, or dissociating patients might
be helped by augmentation with an antiadrenergic agent;
Labile, impulsive, and/or aggressive patients might benefit from
augmentation with an anticonvulsant;
Fearful, hypervigilant, paranoid, and psychotic patients might
benefit from an atypical antipsychotic.
Integrating Iraq War Soldiers into Existing Specialized PTSD
Services
Iraq War service members with stress-related problems may need
to be integrated into existing VA PTSD Residential Rehabilitation
Programs or other VA mental health programs. Approaches to this
integration of psychiatric evacuees will vary and each receiving
site will need to determine its own “best fit” model
for provision of services and integration of veterans. At the
National Center’s PTSD Residential Rehabilitation Program in
the VA Palo Alto Health Care System, it is anticipated that Iraq
War patients will generally be integrated with the
rest of the milieu (e.g., for community meetings, affect
management classes, conflict resolution, communication skills
training), with the exception of identified
treatment components. The latter elements of treatment, in which
Iraq War veterans will work together, will include process,
case management, and acute stress/PTSD education groups (and, if
delivered in groups, exposure therapy, cognitive restructuring, and
family/couples counseling). The thoughtful mixing of returning
veterans with veterans from other wars/conflicts is likely, in
general, to enhance the treatment experience of both groups.
Practitioner Issues
Working with Iraq War veterans affected by war zone trauma is
likely to be emotionally difficult for therapists. It is likely to
bring up many feelings and concerns - reactions to stories of death
and great suffering, judgments about the morality of the war,
reactions to patients who have killed, feelings of personal
vulnerability, feelings of therapeutic inadequacy, perceptions of a
lack of preparation for acute care - that may affect ability to
listen empathically to the patient and maintain the therapeutic
relationship.
27 Koshes
1 suggested that those at greatest risk for strong personal
reactions might be young, inexperienced staff who are close in age
to patients and more likely to identify with them, and technicians
or paraprofessional workers who may have less formal education
about the challenges associated with treating these patients but
who actually spend the most time with patients. Regardless of
degree of experience, all mental health workers must monitor
themselves and practice active self-care, and managers must ensure
that training, support, and supervision are part of the environment
in which care is offered.
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